fillip 


Hist;  Div. 

W 

18 

K25:1m 


Medical  Education 

An    Address    delivered    before    the    Harvard    Medical 
Alumni  Association,  June  26,  1894 

BY 

W.  W.   KEEN,  M.D. 

Professor  of  Principles  and  Practice  of  Surgery  and  Professor  of  Clinical  Surgery 
in  the  Jefferson  Medical  College,  Philadelphia,  etc. 


Reprinted  from  the  Bulletin  of  the  Harvard  Medical  Alumni 
Association,  fune,  i8q4 


MEDICAL   EDUCATION 


Delivered  before  the  Harvard  Medical  Alumni  Association 

June  26,   1894 


BY 


W.   W.  1  KEEN,   M.D. 


PROFESSOR    OF    PRINCIPLES    AND    PRACTICE   OF   SURGERY    AND    PROFESSOR   OF   CLINICAL   SURGERY 
IN    THE    JEFFERSON   MEDICAL   COLLEGE,    PHILADELPHIA,   ETC. 


Reprinted  front  the  Bulletin  of  the  Harvard  Medical  Alumni 
Association,  June,  i8q4 


BOSTON 

Geo.  H.  Ellis,  Primer,  141  Franklin  Street 

1895 


MEDICAL  EDUCATION. 


Mr.  President  and  Gentlemen  of  the  Harvard  Med- 
ical Alumni  Association, —  I  only  wish  that,  in  ac- 
cordance with  your  President's  introduction,  I  could 
rise  to  the  height  of  a  great  argument ;  but  I  must  be 
satisfied  as  nature  built  me.  I  am  very  glad,  I  assure 
you,  to  bring  to  you  the  greeting  of  your  Philadel- 
phia brethren.  The  marble  doorsteps  of  Chestnut 
Street,  so  celebrated  by  Dickens,  greet  the  gilded 
dome  on  Beacon  Hill,  where  the  descendants  of  the 
Pilgrims  and  the  Puritans  live  and  move  and  have 
their  beans.  [Laughter.]  It  is  well  known  that  all 
of  the  streets  grow  grass  in  profusion  ;  and  Philadel- 
phia sometimes,  by  a  sepulchral  description,  is  said  to 
be  a  well  "laid  out"  city.  [Laughter.]  But  I  assure 
you  that,  when  we  get  together  such  lively  corpses  as 
Mitchell  and  Wood  and  Pepper  and  Hare  and  Good- 
ell  and  Wilson  and  Montgomery,  we  have  a  very 
good  time. 

Your  President  was  kind  enough,  in  his  note  ask- 
ing me  to  be  present  on  this  happy  occasion,  to  pro- 
pose that  I  should  speak  on  the  subject  of  Medical 
Education.  It  is  possibly  a  well-worn  theme,  espe- 
cially before  you,  who  have  such  elaborate  reports, 
and  I  am  glad  to  say  such  encouraging  reports,  from 


year  to  year  of  the  progress  of  this  great  School ;  but 
there  are  still  some  points  of  value,  it  seems  to  me, 
which  we  can  consider  here.  I  remember  very  well 
indeed,  in  the  days  of  the  elder  Gross,  hearing  ad 
nauseam  of  medical  education  and  the  progress  that 
we  ought  to  have, —  bushels  of  talk  and  thimblefuls 
of  action ;  but,  after  all,  when  you  consider  it,  these 
discussions,  though  they  led  at  that  time  to  very 
meagre  action,  were  not  without  their  results,  and 
great  results,  too.  They  were  slowly  leavening  the 
whole  lump  of  the  profession.  They  gradually  made 
the  profession  the  support  of  all  the  progress  that  we 
have  seen ;  and  I  am  sure  that  the  medical  schools, 
even,  I  believe,  Harvard  University  itself,  would 
never  have  taken  the  remarkable  steps  in  advance 
which  have  been  taken  in  the  last  few  years,  were  it 
not  for  that  very  constant  talk,  that  very  constant 
working  of  the  leaven  throughout  the  profession. 
[Applause.]  I  trust  the  profession.  I  trust  them 
profoundly.  They  have  ever  been  better  in  that  re- 
spect than  the  schools  till  of  late.     [Applause.] 

There  has  been  certainly  a  remarkable  wave  of 
progress  passing  over  this  country  in  the  matter  of 
medical  education  in  the  last  few  years.  It  has  been 
demonstrated,  first  of  all,  by  the  creation  of  State 
Boards  of  Health,  and  especially  by  the  noble  Illinois 
State  Board  of  Health,  a  body  which  has  done  more 
for  medical  education  than  any  other,  I  believe,  in  this 
country    [applause],    because    it    fixed    an    advanced 


standard.  These  boards  now  have  been  established 
in  almost  all  the  States ;  and  they  have  been  followed 
by  a  still  more  notable  advance, —  namely,  the  estab- 
lishment of  State  Boards  of  Medical  Examiners, 
wholly  independent,  as  they  ought  to  be,  of  the  med- 
ical schools  themselves.  Again,  another  very  remark- 
able indication  is  that  our  universities  and  colleges  all 
over  the  land  are  establishing  distinct  courses  leading 
up  to  those  of  the  various  professional  schools,  medi- 
cine among  them.  And  what  does  this  mean  but 
that  the  medical  schools  want  better  men,  and  that 
the  colleges  are  groins  to  furnish  them  ?  In  addition 
to  this,  another  important  indication  in  the  same  di- 
rection, which  Dr.  Langmaid  has  just  alluded  to, 
is  the  establishment  for  the  first  time  of  a  section 
of  Medical  Pedagogics  in  connection  with  the  Pan- 
American  Medical  Congress.  I  hailed  with  great 
delight  another  similar  indication  in  the  programme 
of  the  American  Surgical  Association  last  month  in 
Washington,  on  seeing  that  one  of  the  leading  papers 
by  the  distinguished  gentleman  who  will  address  you 
later,  our  friend  Dr.  Billings,  of  Washington,  was  enti- 
tled "  Methods  of  Teaching  Surgery."  It  developed 
what  to  my  mind  was  one  of  the  most  fruitful,  and  to 
me  personally  one  of  the  most  useful,  debates  that 
was  held  in  that  body. 

Dr.  Billings  considered  in  that  address  three 
points, —  who  were  to  be  taught,  what  was  to  be 
taught,  and  how  it  was  to  be  taught.     The  very  scope 


of  his  paper,  perhaps,  prevented  what  is,  I  think,  of  as 
much  importance  as  the  methods  of  teaching;  namely, 
the  men  who  teach.  I  would  like  much  to  see  de- 
livered before  all  of  the  boards  of  trustees  of  our  med- 
ical schools  in  this  country  (and  I  think  the  faculties 
might  benefit  quite  as  much)  a  course  of  lectures  on 
"  How  to  conduct  a  Medical  School,  and  who  ought 
to  be  made  Professors  in  it."  [Applause.]  Trustees 
should  not  select  men  because  they  are  their  friends, 
nor  because  they  are  their  family  physicians,  nor  be- 
cause they  are  related  to  them  in  any  way ;  but  there 
should  be  one  sole  requisite  for  the  position  of  a 
teacher,  and  that  is  the  best  and  most  capable  man 
to  teach.  [Applause.]  Moreover,  I  should  be  very 
sorry  indeed  to  see  the  day  when  the  practitioner 
and  the  professor  are  to  be  divorced.  I  do  not  know 
anything  that  is  more  enlivening,  that  renders  a 
man's  lectures  more  juicy,  more  meaty,  than  to  have 
the  varied  experiences,  the  successes,  the  failures,  the 
perplexities,  and  the  responsibilities  of  an  active  prac- 
tice. These  very  men  on  the  benches  before  him  are 
the  men  that  are  to  follow  him  and  his  colleagues  in 
the  actual  practice  of  the  profession ;  and  what  they 
want  is,  not  only  science,  but  the  applications  of 
science  to  every-day  practice.  I  care  not  what  the 
department  is,  be  it  chemistry,  be  it  anatomy,  be  it 
pathological  anatomy,  be  it  any  of  even  the  purely 
scientific  departments  (except  possibly  physiology), 
if  a  man  wants  to  teach  it  in  a  live  way,  in  a  way  that 


will  make  the  knowledge  stick,  in  a  way  that  will 
make  it  interesting  and  attractive  instead  of  a  dry 
statement  of  facts,  he  must  make  the  application  of 
almost  every  fact  in  his  scientific  teaching  to  practice, 
he  must  show  their  practical  bearings  by  cases  drawn 
from  his  own  practice.  [Applause.]  Along  with 
that,  however,  I  believe  that  the  time  will  come  when 
the  men  who  are  professors  in  our  schools  and  at 
the  same  time  practitioners  will  largely  change  their 
methods  of  practice.  A  man  who  is  engrossed  in  a 
very  large  private  practice  often  finds  it  difficult  to 
give  that  amount  of  time  which  the  newer  education 
and  the  newer  methods  of  instruction  of  classes  in 
small  sections  require ;  and  I  believe  that  in  the 
future  the  professors  in  our  medical  schools  will  be 
more  and  more  restricted  in  their  practice  until, 
eventually,  they  will  practise  in  the  hospital,  give 
their  lectures,  and  do  little  or  no  outside  practice. 
This  will  require,  of  course,  very  much  larger  salaries 
than  now  can  be  given,  where  the  income  of  the 
school  is  derived  from  fees ;  and,-  in  order  to  do  this, 
it  is  requisite  to  have  large  endowments  of  the  med- 
ical schools. 

You  all  know  the  great  need,  the  crying  need,  of 
our  medical  schools  at  the  present  day  is  larger  and 
more  thorough  laboratory  facilities ;  and  that  means 
immense  sums  of  money.  I  do  not  know  anything 
more  striking  than  the  figures  given  by  Professor 
Welch    in   a   recent  address,  in  which,  collecting  all 


the  statistics  from  the  medical  schools  for  1893,  he 
showed  that  independently  of  buildings,  I  believe, 
the  permanent  investments  yielding  revenues  to 
medical  schools  in  this  country  were  but  little  over 
$600,000,  and  the  endowments  yielding  revenues 
to  theological  schools  were  $17,600,000.  I  believe 
thoroughly  in  taking  care  of  the  souls  of  the  com- 
munity ;  but  I  put  it  to  you,  and  through  you  to 
the  community,  gentlemen,  whether  there  is  not  a 
vast  disproportion  in  the  discharge  of  a  duty  that 
the  public  owes  to  medical  education  in  a  country 
where  we  cannot  depend  upon  State  aid,  when 
they  have  only  given  a  paltry  $600,000  to  us  as 
contrasted  with  the  millions  for  the  theological  in- 
struction. [Applause.]  Observe  that  these  figures 
apply  only  to  medical  schools,  and  not  to  hospitals ; 
for  to  them  the  community  has  been  wonderfully  and 
praiseworthily  generous.  But,  strange  to  say,  though 
they  have  given  many  millions  for  hospitals,  their 
gifts  to  create  a  profession,  to  educate  the  men  who 
are  to  take  the  care  not  only  of  the  patients  in  these 
hospitals,  but  of  their  own  wives  and  children,  have 
been  but  little  over  a  half  million.  It  is  a  wonderful 
lack  of  perception  —  perception  of  the  fitness  of 
things,  nay,  perception  of  the  necessity  of  things  — 
that  the  community  does  not  see  that  it  is  quite  as 
much  their  duty  to  create  the  facilities  to  make  better 
doctors  as  to  help  the  invalid  and  injured  poor. 
[Applause.] 


I  think  another  of  the  most  important  things 
in  connection  with  such  professors  in  the  medical 
schools,  and  one  that  ought  to  be  a  duty,  is  that  of 
visiting  other  great  medical  centres  than  their  own, 
and  seeing  other  men,  surgeons  and  physicians,  and 
bacteriologists  and  pathologists,  and  chemists  and 
clinicians,  do  their  work.  I  do  not  know  anything 
that  is  more  inspiring  to  me.  I  do  not  know  any- 
thing that  I  learn  more  from  than  a  day  in  Baltimore, 
a  day  in  New  York,  a  day  in  Boston,  from  time  to 
time,  when  I  see  other  men  at  work,  and  I  gain  many 
an  idea,  many  a  good  point,  many  a  wrinkle  that 
serves  me  when  I  am  caught  in  some  case  of  great 
perplexity.  It  ought  to  be  a  duty,  as  well  as  a 
pleasure,  to  every  teacher  to  go  and  see  other  men 
teach ;  and  he  will  learn  one  of  two  things,  either  how 
to  teach  better  or,  in  some  cases,  how  not  to  teach. 
[Applause.] 

There  are  a  number  of  points  that  I  had  noted 
that  I  should  like  to  consider  at  present,  but  I  find 
that  the  time  is  slipping  by,  and  I  must  confine  my- 
self only  to  one  or  two.  Allusion  was  made  in  Dr. 
Billings's  address,  as  I  said,  to  the  students  who  are 
to  be  taught.  I  think  it  is  a  matter  of  great  impor- 
tance, in  considering  the  requirements  for  admission 
(a  subject  which  has  also  been  alluded  to  both  in  the 
report  of  your  Executive  Committee  and  of  the  Presi- 
dent), that  the  good  work  at  the  threshold  of  medi- 
cine should  be    carried    further.     I  am    glad  to  con- 


IO 

gratulate  you,  gentlemen,  on  the  fact  that  it  is  being 
so  nobly  carried  on  by  Harvard  University.     I  do  not 
know  a  better  indication  for  the  future  of  the  medical 
profession  in  this  country  than  the  very  fact  that  was 
alluded  to  by  Dr.  Langmaid  a  moment  ago, —  of  the 
increased  requirements  for  admission  to  be  exacted  in 
1896  in  this  ancient  and  honorable  School.     Now,  it 
is  perfectly  true,  as  has  been  urged  and  as  was  urged 
anew  in  Washington,   that  we  must  remember  that 
medical  education  is  for  the  average  medical  student, 
that  it  is  for  the  medical  students  who  are  going  to 
the  country  cross-roads  to  settle  as  well  as  the  men 
who  are  going  to  settle  on  Beacon  Street,  or,  rather, 
perhaps  I  ought  to  say  on  Boylston  Street.     [Laugh- 
ter.]    We    must    remember,  however,    that    Harvard 
College  can  afford,  gentlemen,  to  take  an  advanced 
stand.     She    can    afford    to    do    so,    because    she    is 
Harvard  College,  because  she  can  set  the  pace  in  this 
matter.     You  need  not  fear  but  that  there  will  be  all 
over  the  country  other  schools  that  will  educate  the 
cross-roads  doctor, —  plenty  of  them.    They  will  spring 
up  —  nay,  they   have    sprung    up  —  almost  in    every 
hamlet,  and  a  good  many  of  them  have  died;  and  the 
more  that  die,  the  better.     As  a  matter  of  fact,  there 
will  always  be  enough  of  those  who  will  educate  men 
for   the   lower  strata;    but    there    ought  to  be  some 
colleges  —  and  Harvard  University  should  be  one  of 
those  colleges,  and  I  am  glad  to  say  that  it  is  one  — 
that  will  educate  the  very  best  doctors.     I  believe  it 


II 

will  be  only  a  short  time  when  you  will  fling  your 
banner  to  the  breeze,  and  say  that  A.B.  or  its  equiv- 
alent shall  be  the  absolute  requirement  for  admission 
to  the  Harvard  Medical  School.  [Applause.]  I  am 
not  one  of  those  who  would,  at  the  present  time 
at  least,  unduly  lengthen  our  course.  I  alluded  a 
moment  ago  to  the  wave  of  medical  improvement 
that  had  swept  over  our  methods  of  education  lately. 
One  of  the  best  evidences  of  this  is  the  large  number 
of  colleges  within  the  very  last  few  years  —  nay,  within 
the  last  two  years  —  that  are  urging  and  insisting  upon 
a  four  years'  medical  course.  It  was  but  last  week,  in 
reading  the  medical  journals,  that  I  found,  way  off 
in  distant  Oregon,  that  the  State  Board  of  Medical 
Examiners  had  issued  notice  that  after  1898  no  per- 
son would  be  admitted  to  practice  in  the  State  of 
Oregon  who  had  not  had  four  years  of  medical  study. 
[Applause.]  We  must  look  to  it  that  in  the  East  we 
are  not  outdone  by  the  West.  Not  only  our  medical 
colleges,  but  our  State  Boards,  must  exact  such  a 
large  and  wise  requirement  as  that,  or  we  will  be 
overrun  with  the  horde  of  doctors  that  cannot  find 
a  place  in  the  West. 

Among  the  methods  of  study  I  can  only  allude  to 
two.  One  is  that  we  have  not  in  this  country  at 
all  such  service  as  there  is  abroad  by  the  Chefs  de 
Clinique.  It  may  possibly  exist ;  but  I  am  not  per- 
sonally aware  of  such  instruction  to  practitioners  as 
draws  not    only  students  from    all  parts  of  our  own 


12 

country,  but  —  as  I  hope  will  not  be  far  hence  —  from 
Europe  as  well.  Only  the  other  day  I  was  reading 
a  report  by  Dr.  Laurent,  of  Brussels,  on  the  medical 
schools  of  this  country.  He  remarked  in  the  very 
beginning  of  it  that  some  people  thought  there  was 
not  very  much  to  be  learned  from  this  country ;  but 
he  added  very  significantly,  "  On  marche  la-bas  a  pas 
de  geant."  I  believe  that  these  giant  strides  will 
soon  carry  us  to  a  position  such  that  men  from 
abroad  will  be  able  to  come  here,  and  get  in  our 
own  schools  exactly  the  teaching  that  many  of  us 
have  had  in  Paris  or  Vienna  or  Berlin,  from  the 
Chefs  de  Clinique,  or  men  who  occupy  similar  posi- 
tions here.  Its  use  in  training  the  chefs  themselves 
as  clinical  teachers  would  by  no  means  be  its  least 
useful  function. 

Second,  a  great  deal  has  been  said  of  late  in 
reference  to  the  value  of  recitation  as  opposed  to 
didactic  instruction.  Now,  I  believe  thoroughly  in 
recitations.  I  am  glad  to  see  that  Harvard  has  estab- 
lished them.  I  believe  they  ought  to  be  official ;  that 
is  to  say,  compulsory.  Every  man  of  the  class  should 
go  before  the  examiner  from  day  to  day,  and  not 
merely  before  the  professor  for  an  examination  at  the 
end  of  his  term ;  and  he  should  be  marked  by  this 
official  quiz-master,  and  his  standing  be  determined 
by  his  recitations  as  well  as  by  his  final  examination. 
But,  gentlemen,  I  do  not  believe  that  the  time  will 
ever  come  when  the  living  voice,  when  the  personality 


13 

of  the  speaker,  will  be  discontinued  and  forgotten.  I 
shall  never  forget,  for  instance,  one  story  that  was 
told  by  dear  old  Charles  D.  Meigs,  whom  you  remem- 
ber, perhaps,  as  being  rather  worsted  in  the  fight  with 
Dr.  Holmes  over  the  contagiousness  of  puerperal 
fever.  It  was  an  illustration  to  emphasize  the  point 
which  he  wished  to  inculcate  in  his  obstetrical  lect- 
ures, that  the  child  should  be  put  to  the  breast  very 
early.  He  gave  a  description,  which  I  will  not  at- 
tempt to  rival, —  for  it  is  one  of  the  most  beautiful 
pieces  of  poetry  in  prose  that  I  ever  heard, —  of  the 
birth  of  Cain.  He  pictured  the  beautiful  bower  to 
which  Eve  retired  and  the  pains  that  she  suddenly  felt, 
which  —  for  it  was  rather  a  novel  experience  to  her 
—  she  thought  must  be  due  to  some  grapes  that  she 
had  eaten  the  day  before  that  had  disagreed  with  her. 
Finally,  she  fainted  away  for  a  moment.  Then,  on 
waking,  she  found  her  slippery  little  Cain,  and,  lifting 
him  up  in  surprise  in  her  arms,  he  fell  into  nature's 
cradle,  and  immediately  took  the  breast.  It  was  a 
very  simple  little  story,  but  it  was  beautifully  told; 
and  to  this  day,  more  than  thirty  years  since,  it  is  as 
fresh  to  me  in  its  grace  and  in  its  lesson  as  it  was 
then.  And,  again,  I  shall  never  forget  the  power  of 
Samuel  D.  Gross.  When  lecturing  on  diseases  of 
joints,  he  began  with  the  question  of  treatment,  look- 
ing round  the  amphitheatre  very  quietly,  he  said, 
"  The  first  requisite  in  the  treatment  of  inflammation 
of  a  joint  is  rest,"  then   after  a  pause,   " rest" ;  and 


14 

then,  rising  to  his  full  height  and  folding  his  arms, 
he  bent  majestically  forward,  and  repeated,  "  In  the 
name  of  God,  Rest."  Now  you  might  read  that  ten 
times  in  a  book,  and  forget  it  the  next  minute ;  but 
once  hear  it  from  the  lips  of  Gross,  with  his  tall  form, 
fine  figure,  and  handsome,  earnest  face,  and  I  would 
defy  you  to  forget  it.     [Applause.] 


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